DIAGNOSTIC NASAL ENDOSCOPIC (DNE) FINDINGS OF A
RANDOM CONTROL TRIAL OF PARTIAL MIDDLE TURBINATE
RESECTION IN FUNCTIONAL ENDOSCOPIC SINUS SURGERY
Dr. Krishna Santosh. B1, Senior Resident, Department of ENT,
GSL Medical College, Rajahmundry.
Dr. N. Samara Simha Reddy2, PG Student, Department of Community
Medicine, GSL Medical College, Rajahmundry
Abstract
Introduction:
Middle turbinate is a dynamic structure which is in a crucial position that
plays a significant role in pathogenesis of rhinosinusitis and headache. The goal
of treating sinus disease with surgery has evolved from removing all diseased
sinus mucosa to specific exenteration of the tissue causing obstruction. Once
ventilation is restored, it is postulated that the mucosa may regain near normal
appearance and function. This study was conducted to evaluate and observe the
benefits following partial middle turbinate resection during FESS on various
symptoms of rhino sinusitis.
Methodology:
This is a random control trial. All the patients with chronic rhino sinusitis, was
selected, studied, and subjected for FESS with partial middle turbinate resection
for 50 patients and 50 patients subjected for FESS with middle turbinate
preservation. All the patients were observed in post operative follow up for five
months and the data was subjected for statistical analysis.
Results:
In our study there was strongly significant p value of 0.000, 0.002, and 0.000
for edema, discharge and synechiae respectively and moderately significant p
value of 0.047 for crusts with respect to DNE findings. In the patients with
partial middle turbinate resection, the post operative DNE results also show
improvement of 80% in edema, 40% in discharge, 40% in scarring, 30% in
synechiae and 20% in crusts compared to the patients with preserved middle
turbinate.
CONCLUSION:
Partial Middle turbinectomy appears to be a positive variable and an adjuvant
technique in patients with inflammatory disease of paranasal sinus, in terms of
the improvement and maintenance of ventilation of osteomeatal complex,
especially if anatomical anomalies present. Partial mi ddle turbinectomy is
recommended whenever exposure is compromised.
Keywords: chronic rhino sinusitis, Partial middle turbinectomy, Functional
Endoscopic sinus surgery, DNE findings
Address for correspondence
Dr. Krishna Santosh.B
Flat no 403, prasanthi jagani heights,
Gazetted officers colony,
Shanty nagar,
Kakinada-533001.
Email :- sankris81@yahoo.com, krrishent@yahoo.in
INTRODUCTION
Chronic rhino sinusitis is considered to be a disease secondary to obstruction
caused by anatomic anomalies and a reactive mucosal edema. Subsequent to
obstruction, inflammation occurs, and with this the morphology of the lining
mucosa of the nasal sinuses changes1. Middle turbinate is a dynamic structure
which is in a crucial position that plays a significant role in pathogenesis of
rhino sinusitis and headache. Anatomical variations like pneumatisation,
paradoxical middle turbinate may also be contributing factors to disease
causation and recurrence. The goal of treating sinus disease with surgery has
evolved from the previous concept of removing all diseased sinus mucosa to
present procedure of specific exenteration of the tissue causing obstruction 2.
Once ventilation is restored, it is postulated that the mucosa may regain near
normal appearance and function. Homeostasis of the large maxillary and frontal
sinuses, with their Ostia located within the anterior ethmoidal complex, is
dependent on proper physiological condition of this region. The anterior part of
the middle turbinate, lying just medial to this area, may exhibit anatomic
deformity and mucosal hyperactivity, exacerbating restrictions to sinus
ventilation and drainage. After surgery to ostiomeatal complex, adhesion or
synechiae formation between the middle turbinate and lateral nasal wall is a
common complication and may lead to re-stenosis of the region and recurrent
disease. The middle turbinate is often carefully preserved at Functional
Endoscopic Sinus Surgery (FESS). However there is no clear understanding of
its importance and its presence may prevent good access to the middle meatus
which could be sometimes detrimental to the surgical result. Various techniques
of managing the middle turbinate have been suggested, but it is still
controversial whether the middle turbinate should be resected as a part of
functional endoscopic sinus surgery. It is therefore important to find out a safe
and effective surgical procedure for proper management of sinonasal disease.
Endoscopic examination by an otolaryngologist is useful in chronic sinusitis.
The specificity of endoscopy is 85% and that of ARS is 75%. Diagnostic nasal
endoscopy is a routine component of the clinical evaluation with evidence of
suspected disease of nose and paranasal sinuses3. Due to the paucity of studies
in assessing the safety, efficacy, advantages, disadvantages and complications
of middle turbinate resection in FESS and to determine the clinically indications
of this approach the present study was undertaken with the following objectives.
1. To study the effects of partial middle turbinate resection in Functional
Endoscopic Sinus Surgery and its effect on various DNE Findings.
2. To assess the basis for decision for performing middle turbinate resection
in routine FESS.
METHODOLOGY:
This is a random control trial carried out over a period of 2 years at ENT
department of a tertiary hospital. Institutional ethical committee permissions
were taken and informed consent was taken from all the participants of the
study. Patients who are suffering from chronic rhino sinusitis and who had to
undergo Functional endoscopic sinus surgery were selected and divided into 2
groups randomly. Group1comprising of 50 patients with Partial Middle
turbinate resection and Group2 (control group) comprising of 50 patients with
Middle turbinate preservation. The inclusion criteria of the study were Patients
with sinonasal disease not responding to medical treatment and age of the
patients between 15 and 60 years belonging to both sexes. The Exclusion
criteria of the study were Patients with any previous sinonasal surgery, Immuno
compromised patients, Patients with acute inflammatory sinonasal disease and
Patients with granulomatous lesions, benign and malignant neoplasms. Detailed
history and clinical examination of each patient is done. All patients are
subjected to diagnostic nasal endoscopy, CT scan of paranasal sinuses, both
coronal and axial cuts taken. Surgical procedure was carried out and recorded
carefully. DNE Findings were noted periodically at intervals of 2 weeks, 2
months and 5 months.
Diagnostic nasal endoscopy was done in all the patients before surgery of both
sides of nose and the findings were noted in aspects of polyps, discharge,
synechiae, crests, scarring, edema. For polyps scoring is given as 0 for absence
of polyps; 1 for middle meatal polyp; 2 for beyond middle meatus. for Edema,
scarring, Crusting, Synechiae scoring is given as 0 as absent; 1for mild; 2 for
severe. in case of Discharge scoring is 0 as no discharge, 1as clear thin
discharge, 2 for thick purulent discharge. The DNE findings of 2 groups were
compared with Difference between two groups and Difference in the same
group at end of 2nd week ,2nd month and 5th month. All the results of study are
presented qualitatively. Results on categorical measurements are presented in
number percentages. Significance is assessed at 5% level of significance, 2x2,
2x3 , 2x4 , Chi square test has been used to find significance of study
parameters on categorical scale between two groups. EPI INFO statistical
software was used.
OBSERVATIONS AND RESULTS:
All the patients in our study underwent diagnostic nasal endoscopic examination
and CT scans, both axial and coronal cuts before surgery. In group 1, 10% of
patients had polyp and in group 2 also only 10% patients had polyps on DNE
assessment. In group 1, 90% and in group 2, 80%of the patients had nasal
discharge. In group 1, 80% of the patients had complete meatal edema and
obstruction. In group 2 all the patients had meatal edema. All patients were
examined with o° and 30° endoscopes and following findings were observed
that In group 1, 5 patients had polyps, out of which 2 patients had polyps in the
middle meatus and 3 patients had polyps beyond the middle meatus . In group 2
also only 5 patients had polyps, out of which 2 patients had polyps in the middle
meatus and 3 patients had polyps beyond the middle meatus. In group 1, 45
patients had discharge, out of which 15 patients had clear thin discharge and 30
patients had thick purulent discharge. In group 2, 40 patients had discharge, out
of which 20 patients had clear thin discharge and 20 patients had thick purulent
discharge. In group 1, 40 patients had severe edema. In group2 all the 50
patients had edema, out of which 35 patients had mild edema and 15 patients
had severe edema.
FIG 1: types of surgery performed
In group1, 20 patients and in group 2, 45 patients had undergone uncinectomy
and middle meatal
antrostomy. In group 1, 25 patients and in group 2, 5 patients had undergone
uncinectomy ,middle meatal antrostomy and ethmoidectomy. In group 1 , 5
patients and in group 2, none had undergone uncinectomy , middle meatal
antrostomy ,ethmoidectomy and sphenoidotomy (fig 1).
TABLE 1 Comparison of DNE Findings between two groups at post op
assessment at 2 weeks
SYMPTO GROU NO. OF
DNE FINDINGS
P
MS
P
PATIEN
Value
0
1
2
TS
50
10
40
0
0.029
OEDEMA Group
1
Group2
50
20
30
0
50
10
40
0
0.000
DISCHAR Group
GE
1
50
30
20
0
Group
2
50
25
25
0
0.314
SCARRIN Group
G
1
50
20
30
0
Group
2
50
30
20
0
0.045
SYNECHI Group
AE
1
50
20
30
0
Group
2
50
20
30
0
0.314
CRUSTS
Group
1
50
25
25
0
Group
2
At the end of 2nd week there was statistically significant p value of 0.000 for
discharge and moderately significant p value of 0.029, 0.045 for edema and
synechiae respectively.( Table 1)
TABLE 2 Comparison of symptom score between two groups at post op
assessment at 2 months
SYMPTO GROU NO. OF
DNE FINDINGS
P
MS
P
PATIEN
Value
0
1
2
TS
50
40
10
0
0.161
OEDEMA Group
1
Group2
50
45
5
0
50
45
5
0
0.012
DISCHAR Group
GE
1
50
35
15
0
Group
2
50
40
10
0
0.002
SCARRIN Group
G
1
50
50
0
0
Group
2
50
35
15
0
0.041
SYNECHI Group
AE
1
50
25
20
5
Group
2
50
40
10
0
0.029
CRUSTS
Group
1
50
30
20
0
Group
2
At the end of 2nd month there was strongly significant p value of 0.002 for
scarring and moderately significant p value of 0.012, 0.041, 0.029 for discharge
, synechiae and crusts respectively.(Table 2)
TABLE 3 Comparison of symptom score between two groups at post op
assessment at 5 months
SYMPTO GROU NO. OF
DNE FINDINGS
P
MS
P
PATIEN
Value
0
1
2
TS
50
50
0
0
0.000
OEDEMA Group
1
Group2
50
25
25
0
50
30
20
0
0.029
DISCHAR Group
GE
1
50
40
10
0
Group
2
50
45
5
0
0.161
SCARRIN Group
G
1
50
40
10
0
Group
2
50
45
5
0
0.000
SYNECHI Group
AE
1
50
25
25
0
Group
2
50
45
5
0
0.000
CRUSTS
Group
1
50
30
20
0
Group
2
At the end of 5th month there was strongly significant p value of 0.000, 0.000,
0.000 for oedema, synechiae, crusts respectively. Moderately significant p value
of 0.029 for discharge. (Table 3)
Table 4: percentage of improvement in SYMPTOM SCORE between two
groups
SYMPTOMS
GROUP 1
GROUP 2
P VALUE
% OF IMPROVEMENT
80%
10%
0.0000
OEDEMA
40%
20%
0.0002
DISCHARGE
40%
40%
1.0000
SCARRING
30%
10%
0.0000
SYNECHIAE
20%
10%
0.0470
CRUSTS
There was strongly significant p value for oedema, discharge, synechiae.
Moderately significant p value for crusts. Not much significant p value for
scarring.(Table 4)
No major surgical complications occurred in this study. There was no case of
blindness, diplopia, csf leak, epiphora. Blood loss was not much significant and
no patient required blood transfusion.
DISCUSSION;- In our study there was strongly significant p value of 0.000,
0.002, 0.000 for oedema, discharge and synechiae respectively. In our study
there was moderately significant p value of 0.047 for crusts. There was 80%
improvement in group 1 patients and 10% improvement in group2 patients; with
respect to oedema. There was 40% improvement in group 1 patients and 20%
improvement in group2 patients; with respect to discharge. There was 30%
improvement in group 1 patients and 10% improvement in group2 patients; with
respect to synechiae. There was 20% improvement in group 1 patients and 10%
improvement in group2 patients; with respect to crusting. Toffel Paul H
reported in his own article in 1989 which that, early endoscopic series of 129
patients with partial middle turbinectomy , showed a much lower synechiae and
middle meatal antrostomy failure rate(3% compared to turbinate preservative
procedure)4. In a study by Davis et al. showed that the subgroup of patients who
had undergone partial middle turbinate resection had overall patency rate
slightly higher (96.5%) compared to patients with middle turbinate
preservation5. Lamear et al and Beilingmaier reported that partial middle
turbinate resections were safe and produced, antrostomy and omc patency rates
30% higher than the middle turbinate preservation technique6. A study by
S.P.Gulati et al showed that only 1 patient had synechiae out of 40 patients who
had partial middle turbinate resection but 5 patients had synechiae out of 40
patients who had middle turbinate preservation7.
Our study shows that here was good improvement in post operative symptoms
and diagnostic nasal endoscopy in patients with partial middle turbinate
resection compared to the patients with middle turbinate preservation. In a study
by Thomas E Havas and Lowinger the outcome of the operative complications
are as follows: Epistaxis 1 out of 597 patients with middle turbinate
preservation and 2 patients out of 509 with middle turbinate resection 8.
Synechiae was in 51 patients out of 597 who undergone FESS with middle
turbinate preservation and 0 in 509 patients with middle turbinate resection. Out
of 597 patients with middle turbinate preservation 93 patients required revision
surgery and 36 patients had required revision surgery out of 509 patients who
had undergone FESS with middle turbinate resection.
Partial middle turbinectomy seems to be reasonable because it probably
prevents adhesions between the remaining middle turbinate and freshly incised
lateral nasal wall. Chances of recurrent polypoidal rhinosinusitis is less with
group1 (MTR) patients and synechiae , crusting, edema were statistically
significant. Our results also concur with Kennedys finding the most important
predictive factor and success of FESS is the extent of rhino sinusitis before
surgery. In both the groups about 7 patients (15.8%) were having higher stage of
disease initially and were more likely to have slow healing and recurrence of
disease in long term. Patient with polyp and seasonal allergy have increased rate
of closure of middle meatal antrostomy and recurrence of polyp and synechiae.
There was statistically significant difference in edema, synechiae, crusts, nasal
obstruction, nasal discharge and sense of smell. Partial middle turbinectomy
appears to be a positive variable and an adjuvant technique in patients with
inflammatory disease of paranasal sinus, in terms of the improvement of
maintenance of ventilation of osteomeatal complex, especially if anatomical
anomalies are present. Partial middle turbinectomy is recommended whenever
exposure is compromised. It also enhanced the access for endoscopic
examination and cleaning of maxillary sinus, ethmoid infundibulum, and frontal
recess can be achieved. However long term follow up, as more than 1 year is
required to assess the postoperative outcome of the above surgical study. No
significant short or long term complications have resulted from partial resection
of middle turbinate. In addition to usual patients having benefit from middle
turbinate resection other patients with anatomic changes like high septal
deviation of perpendicular plate of ethmoid, obstructing middle meatus. Patient
with narrow nasal vault, a septal spur impinging on middle turbinate, large
conchabullosa and paradoxically turned middle turbinate also had significant
improvement with this above procedure. Partial middle turbinectomy did not
impair nasal function. Indeed the procedure significantly enhances these
parameters of nasal function. In small series of patients, there was
significant improvement with respect to symptoms like nasal obstruction and
nasal discharge. The surgical results were enhanced, where as disruption of
nasal physiology and subsequent atrophic rhinitis was avoided. By leaving
superior and posterior part of middle turbinate we had preserved important
landmarks for future surgery. As per the study following are indications of
partial middle turbinate resection are elimination of source of middle meatus
obstruction,
prevention
of
postoperative
synechiae,
pneumatised
middleturbinate or polypoidal degeneration of mucosa and improved access to
posterior ethmoidal and sphenoidal sinuses.
ACKNOLEDGEMENTS: We acknowledge with thanks for cooperation
given by Dr.M.Amarnath, Professor, Dept of Community medicine, GSL
Medical College, Rajahmundry.
CONFLICT OF INTEREST : We declare that there is no conflict of interest
SOURCE OF FUNDING: SELF
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